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psnet.ahrq.gov/node/843054/psn-pdf
January 25, 2023 - The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated
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psnet.ahrq.gov/node/73665/psn-pdf
September 01, 2021 - The most common safety events included pressure injuries or other skin integrity events, falls,
and
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psnet.ahrq.gov/node/60027/psn-pdf
January 01, 2021 - Improvements in medication errors and hospital-
acquired pressure injuries were observed, but employee
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psnet.ahrq.gov/issue/patient-characteristics-and-occurrence-never-events
February 15, 2011 - October 30, 2024
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … From research to practice: factors affecting implementation of prospective targeted injury-detection
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psnet.ahrq.gov/node/60551/psn-pdf
January 01, 2021 - The authors discuss major CMS payment policy changes and their intersection
with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the
decline trends in PSI rates
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psnet.ahrq.gov/issue/implementation-centers-medicare-medicaid-services-nonpayment-policy-preventable-hospital
September 16, 2020 - The study looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated … hospitals had significantly fewer of these hospital-acquired conditions, except for patient falls with injury
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psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops
October 10, 2018 - February 21, 2018
Early identification and evaluation of severe pressure injuries. … December 8, 2010
National safety effort targets perinatal injuries.
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - , including self-induced "digital trauma." … Similar to bleeding from other sites, it is most effectively controlled by direct pressure. … Not only do these injuries create additional bleeding sources, they are commonly mistaken for the original … septum to avoid a septal perforation.( 5 ) Moisturizing the nasal cavity is important while the cautery wound … August 21, 2013
WebM&M Cases
Missing the Point—Eye Injury
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psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
October 30, 2024 - Overall, HAC rates declined over the 2 years following implementation of the program, with only rates of pressure … Are evidence-based practices associated with effective prevention of hospital-acquired pressure … December 21, 2017
Complexity bias in the prevention of iatrogenic injury: why specific
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psnet.ahrq.gov/issue/exploring-stakeholder-perceptions-around-implementation-operating-room-black-box-patient
November 04, 2020 - mostly supportive of the OR Black Box, but several potential barriers were identified, such as time pressures … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury … August 8, 2012
Role of intraoperative cholangiography in avoiding bile duct injury. … March 31, 2010
Laparoscopic bile duct injury: understanding the psychology and heuristics
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psnet.ahrq.gov/periodic-issue/periodic-issue-394
June 28, 2023 - characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury … and pressure ulcers). … and pressure ulcers). … This Month’s WebM&Ms
WebM&M Cases
Ventricular Wall Injury during a Diagnostic … factors and the importance of effective team communication and immediate recognition of iatrogenic injuries
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psnet.ahrq.gov/issue/patient-safety-people-experiencing-advanced-dementia-hospital-video-reflexive-ethnography
November 16, 2022 - July 17, 2024
Early identification and evaluation of severe pressure injuries. … April 6, 2022
Clinical characteristics and short-term outcomes of acute kidney injury
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psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - reports involved
interunit/department/team transfers and the majority (69%) of incidents were related to pressure … injuries,
falls, medication, and documentation errors.
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psnet.ahrq.gov/node/836964/psn-pdf
April 20, 2022 - The most common
preventable events were medication events, pressure injuries, and healthcare-associated
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psnet.ahrq.gov/node/60228/psn-pdf
April 15, 2020 - the identified events resulted in a delay in
care and 41% resulted in temporary harm (e.g., falls, pressure … injuries, skin tears, abrasions).
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes
that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-
773. … Hyperventilation in head injury: a review. Chest.
2005;127:1812-1827. [go to PubMed]
5.
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psnet.ahrq.gov/node/45036/psn-pdf
February 15, 2017 - provide intensive
rehabilitation to patients recovering from hospitalization for an acute illness or injury … Nearly half of the events were considered preventable,
with the most common types of events including pressure
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psnet.ahrq.gov/issue/adverse-events-experienced-homecare-patients-scoping-review-literature
October 19, 2022 - Categories included adverse drug events and line-related problems as well as the expected focus on wounds … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient's injuries included a left shoulder dislocation and a minimally displaced fracture of a thoracic … After reviewing the medical records, the PT noted the initial shoulder injury on admission. … In addition to providing a general assessment, the PT expressed concern that the shoulder injury had
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - The most frequent triggers included pressures from high census; environmental overload; chronic, unresolved … Multifactorial interventions to reduce duration and variability in delays to identification of serious injury … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.